Proposal Title: Outcomes, Costs and Trends in Dialysis Timing in VA PI: Paul L. Hebert, PhD PROJECT SUMMARY/ABSTRACT Objectives: Chronic kidney disease (CKD) is a progressively debilitating, highly prevalent, and disproportionately costly disease. Initiation of long-term dialysis has significant financial and quality of life implications for the patient as well as costs to the health care system and society. The decision to dialyze is often based on declining levels of the estimated Glomerular Filtration Rate (eGFR) and patient symptoms of uremia, such as fatigue and weight loss, but optimal timing for dialysis is not well understood. There is little evidence to evaluate the benefits, if any, of referral to dialysis at higher levels of kidney function. The objectives of this study are to address the effects of early versus late dialysis for veterans with chronic kidney disease receiving care at the VA. Specific aims are to 1) determine if trends toward earlier dialysis apparent at the national level are also found within the VA; 2) estimate the health benefits for VA patients of earlier initiation of dialysis compared to later; and 3) estimate the medical cost of earlier initiation of dialysis for VA patients. Research Plan: The proposed study is a retrospective analysis of VA administrative and clinical data, and linked VA-U.S. Renal Data System (USRDS) data. Methodology: For Aim 1, we will identify veterans and non-veterans who initiated dialysis from 1995 to 2007 using the linked VA-USRDS databases. Using descriptive statistics and regression analysis, we will compare trends in early initiation of dialysis (measured by eGFR at dialysis) for VA versus non-VA patients, and explore regional variation in eGFR and variations within and between VA nephrologists. For Aims 2 and 3, we will use a subset of VA patients who initiated dialysis between 2000 and 2006 to estimate the health benefits of early dialysis (eGFR>7) vs. late dialysis. Using a combination of propensity analysis, logistic regression and instrumental variables analysis, we will assess differences in mortality, morbidity and costs for early-dialysis versus late-dialysis patients.